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{{WBRQuestion
{{WBRQuestion
|QuestionAuthor={{Rim}}
|QuestionAuthor= {{SSK}} (Reviewed by Serge Korjian)
|ExamType=USMLE Step 1
|ExamType=USMLE Step 1
|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
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|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
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|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|Prompt=A 32 year old woman presents to the gynecology clinic for 3 months of absent menstruation. The patient has been trying to get pregnant for the past year but has been unsuccessful. She reports decreased libido and episodes of bilateral milky breast discharge. Which of the following visual field patterns is most likely present in this patient?
|Prompt=A 32-year-old woman presents to the gynecology clinic for 3 months of absent menstruation. The patient has been trying to get pregnant for the past year but has been unsuccessful. She reports decreased libido and episodes of bilateral milky breast discharge. She also explains that she has been having difficulty driving and has failed a road test twice. Which of the following visual field patterns is most likely present in this patient?
|Explanation=[[Image:Optic_tracts_with_explanation.jpg|900px]]
|Explanation=[[Image:Optic_tract_with_explanation.jpg|900px]]
 
 
The patient has a typical presentation of [[hyperprolactinemia]] which is usually characterized by [[amenorrhea]], [[infertility]], decreased [[libido]], bilateral milky breast discharge, and [[osteoporosis]] if untreated. The most common cause of hyperprolactinemia is a pituitary tumor known as [[prolactinoma]]. As the prolactinoma enlarges it impinges on the [[optic chiasm]] leading to bitemporal hemianopia manifesting as loss of peripheral vision with patients complaining of bumping into objects and having difficulty with driving.
 


Educational objective: Prolactinomas are prolactin secreting tumors of the pituitary that can enlarge to compress the underlying optic chiasm and cause bitemporal hemianopia.


The patient in this scenario has the typical presentation of [[hyperprolactinemia]] which is usually characterized by [[amenorrhea]], [[infertility]], decreased [[libido]], bilateral milky breast discharge, and [[osteoporosis]] if untreated. The most common cause of hyperprolactinemia is a pituitary tumor of the lactotroph cells known as a [[prolactinoma]]. As the prolactinoma enlarges it impinges on the [[optic chiasm]] leading to bitemporal hemianopia defined as a bliateral loss of peripheral vision. Patients classically complain of bumping into objects while walking or of difficulty driving (ex. cannot see oncoming car when switching lanes).


References:
Jay WM. Visual field defects. Am Fam Physician. 1981;24(2):138-42.
|AnswerA=[[Image:Visual1.gif]]
|AnswerA=[[Image:Visual1.gif]]
|AnswerAExp=Homonymous hemianopia involves loss of vision on one side. It usually occurs due to a lesion to the optic tracts or a PCA stroke although the latter usually has associated macular sparing. This lesion is not seen with prolactinomas.
|AnswerAExp=Homonymous hemianopia involves loss of vision on one side. It usually occurs due to a lesion to the optic tracts or a PCA stroke although the latter usually has associated macular sparing. This lesion is not seen with prolactinomas.
|AnswerB=[[Image:Visual2.gif]]
|AnswerB=[[Image:Visual2.gif]]
|AnswerBExp=Right upper quadrantopia is characterized by loss of vision in the right upper quadrant of the visual field. It usually occurs with left temporal lesions due to the interruption of the left Meyer's loop. Prolactinomas do not affect the temporal lobe.
|AnswerBExp=Right upper quadrantanopia is characterized by loss of vision in the right upper quadrant of the visual field. It usually occurs with left temporal lesions due to the interruption of the left Meyer's loop. Prolactinomas do not affect the temporal lobe.
|AnswerC=[[Image:Visual3.gif]]
|AnswerC=[[Image:Visual3.gif]]
|AnswerCExp=Left nasal hemianopia usually occurs with lesions of the internal carotid artery (internal carotid thrombosis) that occur lateral to the optic chiasm. This presentation is not typical of prolactinomas.
|AnswerCExp=Left nasal hemianopia usually occurs with lesions of the internal carotid artery (internal carotid thrombosis) that occur lateral to the optic chiasm. This presentation is not typical of prolactinomas.
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|AnswerDExp=This lesion portrays bitemporal hemianopia seen in large prolactinomas that abut the optic chiasm.
|AnswerDExp=This lesion portrays bitemporal hemianopia seen in large prolactinomas that abut the optic chiasm.
|AnswerE=[[Image:Visual5.gif]]
|AnswerE=[[Image:Visual5.gif]]
|AnswerEExp=Right lower quadrantopia is characterized by loss of vision in the right lower quadrant of the visual field. It usually occurs with left parietal lesions due to the interruption of the left dorsal optic radiations. Prolactinomas do not usually affect the parietal lobe.
|AnswerEExp=Right lower quadrantanopia is characterized by loss of vision in the right lower quadrant of the visual field. It usually occurs with left parietal lesions due to the interruption of the left dorsal optic radiations. Prolactinomas do not usually affect the parietal lobe.
|EducationalObjectives=Prolactinomas are prolactin secreting tumors of the pituitary that can enlarge to compress the underlying optic chiasm and cause bitemporal hemianopia.
|References=Jay WM. Visual field defects. Am Fam Physician. 1981;24(2):138-42.
|RightAnswer=D
|RightAnswer=D
|WBRKeyword=Bitemporal hemianopia, Prolactinoma, Visual field defects
|WBRKeyword=Bitemporal hemianopia, Prolactinoma, Visual field defects, Optic chiasm,
|Approved=No
|Approved=Yes
}}
}}

Latest revision as of 01:02, 28 October 2020
Author [[PageAuthor::Serge Korjian M.D. (Reviewed by Serge Korjian)]]
Exam Type ExamType::USMLE Step 1
Main Category MainCategory::Pathophysiology
Sub Category SubCategory::Head and Neck, SubCategory::Neurology
Prompt [[Prompt::A 32-year-old woman presents to the gynecology clinic for 3 months of absent menstruation. The patient has been trying to get pregnant for the past year but has been unsuccessful. She reports decreased libido and episodes of bilateral milky breast discharge. She also explains that she has been having difficulty driving and has failed a road test twice. Which of the following visual field patterns is most likely present in this patient?]]
Answer A [[AnswerA::]]
Answer A Explanation AnswerAExp::Homonymous hemianopia involves loss of vision on one side. It usually occurs due to a lesion to the optic tracts or a PCA stroke although the latter usually has associated macular sparing. This lesion is not seen with prolactinomas.
Answer B [[AnswerB::]]
Answer B Explanation [[AnswerBExp::Right upper quadrantanopia is characterized by loss of vision in the right upper quadrant of the visual field. It usually occurs with left temporal lesions due to the interruption of the left Meyer's loop. Prolactinomas do not affect the temporal lobe.]]
Answer C [[AnswerC::]]
Answer C Explanation AnswerCExp::Left nasal hemianopia usually occurs with lesions of the internal carotid artery (internal carotid thrombosis) that occur lateral to the optic chiasm. This presentation is not typical of prolactinomas.
Answer D [[AnswerD::]]
Answer D Explanation AnswerDExp::This lesion portrays bitemporal hemianopia seen in large prolactinomas that abut the optic chiasm.
Answer E [[AnswerE::]]
Answer E Explanation [[AnswerEExp::Right lower quadrantanopia is characterized by loss of vision in the right lower quadrant of the visual field. It usually occurs with left parietal lesions due to the interruption of the left dorsal optic radiations. Prolactinomas do not usually affect the parietal lobe.]]
Right Answer RightAnswer::D
Explanation [[Explanation::


The patient in this scenario has the typical presentation of hyperprolactinemia which is usually characterized by amenorrhea, infertility, decreased libido, bilateral milky breast discharge, and osteoporosis if untreated. The most common cause of hyperprolactinemia is a pituitary tumor of the lactotroph cells known as a prolactinoma. As the prolactinoma enlarges it impinges on the optic chiasm leading to bitemporal hemianopia defined as a bliateral loss of peripheral vision. Patients classically complain of bumping into objects while walking or of difficulty driving (ex. cannot see oncoming car when switching lanes).
Educational Objective: Prolactinomas are prolactin secreting tumors of the pituitary that can enlarge to compress the underlying optic chiasm and cause bitemporal hemianopia.
References: Jay WM. Visual field defects. Am Fam Physician. 1981;24(2):138-42.]]

Approved Approved::Yes
Keyword WBRKeyword::Bitemporal hemianopia, WBRKeyword::Prolactinoma, WBRKeyword::Visual field defects, WBRKeyword::Optic chiasm
Linked Question Linked::
Order in Linked Questions LinkedOrder::
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